Robotically assisted totally endoscopic coronary bypass surgery

Historical evolution of robot-assisted cardiac surgery: a 25-year journey

Many patients and surgeons today favor the least invasive access to an operative site. The adoption of robot-assisted cardiac surgery has been slow, but now has come to fruition. The development of modern surgical robots took surgeons close collaboration with mechanical, electrical, and optical engineers. Moreover, the necessary project funding required entrepreneurs, federal grants, and venture capital. Non-robotic minimally invasive cardiac surgery paved the way to the application of surgical robots by making changes in operative approaches, instruments, visioning modalities, cardiopulmonary perfusion techniques, and especially surgeons' attitudes. In this article, the serial development of robot-assisted cardiac surgery is detailed from the beginning and through clinical application. Included are references to the historical and most recent clinical series that have given us the evidence that robot-assisted cardiac surgery is safe and provides excellent outcomes. To this end, in many institutions these procedures now have become a new standard of care. This evolution reflects Sir Isaac Newton's famous 1676 quote when referring to Rene Descartes, "If have seen further [sic] than others, it is by standing on the shoulders of giants".

A Practical Approach to Hybrid Coronary Revascularization

Combined surgical and percutaneous coronary revascularization, ie, hybrid coronary revascularization (HCR) consists of surgical left internal mammary artery (LIMA) bypass to the left anterior descending artery (LAD) and percutaneous revascularization of other diseased coronary arteries. Developed as a 1-stage procedure, HCR has not been widely adopted by the cardiovascular community. The recommended minimally invasive approach through a small left thoracotomy incision is technically demanding, and same-day percutaneous revascularization requires a hybrid operating room that is not available in most hospitals. In this review, we consider present HCR protocols, barriers to widespread adoption of HCR, and we give special attention to the surgical approach for the LIMA graft to the LAD and the timing of percutaneous revascularization. We conclude that grafting the LIMA to the LAD through a median sternotomy approach and delaying the percutaneous revascularization may facilitate the widespread use of HCR in patients with multivessel coronary artery disease and a low to intermediate Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score.

Hiatal hernia after robotic-assisted coronary artery bypass graft surgery

Background

The aim of the present study is to determine the incidence/progression of hiatal hernia (HH) after robotic-assisted coronary artery bypass grafting (RA-CABG) surgery.

Methods

We reviewed the pre- and post-operative computed tomography (CT) of 491 patients who underwent RA-CABG between 2000 and 2017. Post-operative CT was acquired prospectively in a research protocol. CT was reviewed to assess the presence and the size of HH.

Results

We found 444/491 (90.4%) had pre-operative CT, while 201/491 (40.9%) had post-operative CT. In total, 155/491 (31.6%) had both pre- and long-term post-operative CT with a mean follow-up of 6.2 (±3.5) years. HH was more prevalent on post-operative CT, 64/155 (41.3%) compared to pre-operative CT, 44/155 (28.4%), P<0.0001. The diameter of pre-existing HH 2.8 (±1.8) cm was significantly greater after surgery 3.9 (±2.5) cm, P<0.0001. As well the volume of the pre-existing HH 5.8 (4.4-9.2) mL (quartile) was significantly greater after surgery 14.1 (7.2-64.9) mL, P<0.0001. 20/155 (12.9%) had a newly developed HH after RA-CABG. A binary multivariate regression including HH risk factors showed that male gender is a predictor of developing a HH after RA-CABG with Hazard Ratio of 3.038, confidence interval (1.10-8.43), P=0.033.

Conclusions

RA-CABG is associated with an increased risk of developing HH and increases the size of pre-existing HH.

Minimally invasive coronary surgery

Minimally invasive options for coronary artery bypass graft (CABG) surgery progressed dramatically in the last decades. Minimally invasive CABG surgery is presented trough these forms: minimally invasive direct coronary artery bypass (MIDCAB), endoscopic atraumatic coronary artery bypass (EndoACAB), robot-assisted direct coronary artery bypass (RADCAB), total endoscopic coronary artery bypass (TECAB), and hybrid coronary revascularisation (HCR). Unfortunately, these are still limited only to the specialised centres across the world and have not been accepted by the majority of cardiac surgeons. A surgeon who is starting to practice minimally invasive CABG surgery needs to be ready for long duration of the interventions, higher rate of conversions to sternotomy and significant learning curve. Excellent results that have been published on the subject of minimally invasive revascularisation methods support the potential of these alternative approaches to evolve in the near future.

Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting

Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.

Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Systematic Review of Clinical Outcomes from the Past two Decades

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

State-of-the-Art Coronary Artery Bypass Grafting: Patient Selection, Graft Selection, and Optimizing Outcomes

Despite the progressive expansion of clinical indications for percutaneous coronary intervention and the increasingly high risk profile of referred patients, coronary artery bypass grafting (CABG) remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates. Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes. A surgical approach individualized to the patients' clinical and anatomic characteristics, and surgeon and team experience, are key to excellent outcomes. Current evidence regarding patient selection, indications, graft selection, and potential strategies to optimize outcomes in patients treated with CABG is summarized.

A review of hybrid coronary revascularization

Purpose

Hybrid coronary revascularization is an emerging treatment strategy for coronary artery disease. We will review the reasons for the development of this strategy, describe surgical techniques, and review outcomes. Finally, we will discuss the future of hybrid revascularization and explain why it will grow as a treatment modality.

Methods

For this review, we conducted an unstructured review of the literature for articles related to hybrid coronary revascularization, bypass surgery, and percutaneous coronary interventions.

Results

Hybrid coronary revascularization has been shown in large series to have excellent results. These include fast recovery time, low mortality and rates of complications, and excellent surgical graft patency. There may be increased need for revascularization over conventional bypass surgery.

Conclusions

The combination improved surgical techniques including a robotic surgery platform, as well as the ever-improving efficacy and durability of coronary stents have made hybrid coronary revascularization an attractive option for many patients. It offers a minimally invasive approach to surgery while avoiding the poor patency of saphenous vein grafts. In appropriately selected patients, this may be an ideal treatment strategy that minimizes risks and maximizes short- and long-term benefits.

Long-Term Clinical and Computed Tomography Angiographic Follow-up After Totally Endoscopic Coronary Artery Bypass Grafting

OBJECTIVE

Totally endoscopic coronary artery bypass grafting was shown to be feasible and safe, with excellent clinical and angiographic mid-term results. Data on long-term outcome are lacking. Therefore, we aimed to investigate the long-term rate of major adverse cardiac and cerebrovascular events and left internal mammary artery patency rate in patients undergoing arrested heart totally endoscopic coronary artery bypass grafting.

METHODS

From 2001 to 2012, a total of 208 arrested heart-totally endoscopic coronary artery bypass grafting patients were prospectively included. Mean ± SD age was 58.8 ± 9.4 years, and mean ± SD Society of Thoracic Surgeons score was 0.5 ± 0.5%. Major adverse cardiac and cerebrovascular events were defined as a composite of death, myocardial infarction, stroke, re-percutaneous coronary intervention, re-coronary artery bypass graft, and target vessel revascularization. Left internal mammary artery patency was assessed using cardiac computed tomography and depicted according to the established Fitzgibbon classification. Mean ± SD follow-up was 6.9 ± 2.3 years.

RESULTS

At 1, 5, and 10 years, survival rate was 100%, 98.3%, and 95.8%, respectively. The freedom from clinical events at 1, 5, and 10 years were major adverse cardiac and cerebrovascular events (93.5%, 85.9%, and 83.0%), myocardial infarction (99.0%, 97.4%, and 95.9%), target vessel revascularization (96.0%, 94.3%, and 91.7%), re-percutaneous coronary intervention (94.5%, 91.6%, and 84.2%), and re-coronary artery bypass graft (100%, 99.5%, and 99.5%), respectively. Left internal mammary artery patency rate at 1, 5, and 10 years was 100%, 94.9%, and 88.1%, respectively.

CONCLUSIONS

Arrested heart-totally endoscopic coronary artery bypass grafting shows excellent clinical long-term results with a left internal mammary artery patency rate comparable with conventional coronary artery bypass graft at 10 years after surgery.

Factors causing prolonged mechanical ventilation and peri-operative morbidity after robot-assisted coronary artery bypass graft surgery

Robot-assisted coronary artery bypass graft [robot-assisted (coronary artery bypass grafting (CABG)] surgery is the latest treatment for coronary artery disease. However, the surgery extensively affects cardiac and pulmonary function, and the risk factors associated with peri-operative morbidity, including prolong mechanical ventilation (PMV), have not been fully examined. In this retrospective cohort study, a total of 382 patients who underwent robot-assisted internal mammary artery harvesting with mini-thoracotomy direct-vision bypass grafting surgery (MIDCABG) from 2005 to 2012 at our tertiary care hospital were included. The definition of PMV was failure to wean from mechanical ventilation more than 48 h after the surgery. Risk factors for PMV, and peri-operative morbidity and mortality were analyzed with a multivariate logistic regression model. Forty-three patients (11.3%) developed PMV after the surgery, and the peri-operative morbidity and mortality rates were 38 and 2.6%, respectively. The risk factors for PMV were age, left ventricular ejection fraction (LVEF), the duration of one-lung ventilation for MIDCABG (beating time), and peak airway pressure at the end of the surgery. Furthermore, age and anesthesia time were found to be independent risk factors for peri-operative morbidity, whereas age, LVEF, and anesthesia time were the risk factors for peri-operative mortality. These findings may help physicians to properly choose patients for this procedure, and provide more attention to patients with higher risk after surgery to achieve better clinical outcomes.

Hybrid coronary revascularization for the treatment of multivessel coronary artery disease

Coronary artery disease (CAD) has typically been treated either medically, with percutaneous coronary intervention (PCI), or with coronary artery bypass grafting (CABG). As advances in stent technology and minimally invasive surgery have developed, a third option has emerged: hybrid coronary revascularization (HCR). In HCR, minimally invasive CABG and PCI are both employed to treat a single patient, often during the same hospital stay. Patients appropriate for this technique vary widely, from low-risk patients with low SYNTAX lesions outside the left anterior descending artery (LAD), to high-risk patients with multiple comorbidities who are felt by the heart team to benefit most by avoiding a sternotomy. Across both our experience and other series in the literature, mortality with HCR is around 1%. Hospital length of stay is less than one week, and typically less than after conventional CABG, but longer than with isolated PCI. Return to baseline activity is substantially shorter after minimally invasive CABG compared to conventional CABG due to the avoidance of a sternotomy; deep sternal wound infections are entirely avoided. Mid-term need for repeat revascularization may be higher with HCR, though randomized data are lacking. In conclusion, HCR is an evolving method to treat multivessel CAD with favorable early results in high volume centers, though growth in the field is limited by surgical experience and success with minimally invasive techniques.

Robotic Versus Conventional Coronary Artery Bypass Grafting: Direct Comparison of Long-Term Clinical Outcome

OBJECTIVE

Robotic coronary artery bypass grafting (CABG) was shown to be a safe and feasible method for the treatment of coronary artery disease in highly selected patients. However, long-term outcome data comparing robotic CABG with conventional CABG are still missing. Therefore, we aimed to compare robotic with conventional CABG in terms of perioperative and long-term outcomes.

METHODS

Of 2947 consecutive elective patients with coronary artery disease operated at a single center between 2001 and 2013, 280 underwent robotic CABG. After propensity score matching, 134 pairs of robotic versus conventional CABG (age = 62 ± 10 years, log EuroScore = 2.4 ± 2.4% vs. mean ± SD age = 63 ± 10 years, log EuroScore 2.5 ± 1.7%, respectively; all P > 0.05) were formed. The mean ± SD follow-up was 6.6 ± 3.2 years.

RESULTS

There was no difference in perioperative mortality (robotic = 0% vs. conventional = 1.5%, P = 0.154), myocardial infarction (robotic = 0% vs. conventional = 2.2%, P = 0.08), and stroke rate (robotic = 0% vs. conventional = 0.7%, P = 0.318) between the groups. Longer cardiopulmonary bypass (robotic = 112 ± 100 minutes vs. conventional = 67 ± 48 minutes, P < 0.0001) and cross-clamp times (robotic = 68 ± 54 minutes vs. conventional = 38 ± 27 minutes, P < 0.0001) were observed in robotic patients. Long-term follow-up yielded equivalent results in terms of survival (1, 5, and 10 years: robotic = 99.3%, 96.9%, and 81.3% vs. conventional = 96.3%, 92.2%, and 82.6%, respectively; log-rank P = 0.187) and freedom from major adverse cardiac and cerebral events at 1, 5, and 10 years after procedure (robotic = 90.6%, 77.7%, 70.1% vs. conventional = 94.1%, 82.2%, 66.6%; log-rank P = 0.790).

CONCLUSIONS

Long-term outcomes of robotic CABG are comparable with conventional CABG for selected patients. Longer operative times of robotic CABG do not influence the excellent long-term outcomes.

Comparative Analysis of Perioperative and Mid-Term Results of TECAB and MIDCAB for Revascularization of Anterior Wall

OBJECTIVE

Totally endoscopic coronary artery bypass (TECAB) and minimally invasive direct coronary artery bypass (MIDCAB) grafting through minithoracotomy are currently the two minimally invasive surgical techniques of left ventricular anterior wall revascularization. We aimed to compare both techniques in terms of perioperative and mid-term results.

METHODS

Arrested heart TECAB was carried out in 204 patients with a median (range) age of 60 (53-76) years and a median (range) EuroSCORE I of 2 (0-3). Minimally invasive direct coronary artery bypass was performed in 60 patients with a median (range) age of 66 (54-75) years and a median (range) EuroSCORE I of 2 (1-5). Both techniques were used for single or sequential internal mammary artery grafts to the anterior wall. Operative times, conversion rates, and surgical complications as well as mid-term results were compared between the groups after a median follow-up of 36 months.

RESULTS

No perioperative deaths were noted. Rates of myocardial infarction (TECAB: 1.5% vs MIDCAB: 0%, P = 0.463) and stroke (TECAB: 1.5% vs MIDCAB: 0%, P = 0.454) were not significantly different between the groups. Total operative times were longer in the TECAB compared with the MIDCAB group [292 (250-345) minutes in TECAB versus 201 (173-289) minutes in MIDCAB (P < 0.001)]. Intensive care unit stay and total length of stay were similar between the groups. There was no difference in mid-term survival (TECAB: 1.5% vs MIDCAB: 1.7%, P = 0.298) and freedom from major adverse cardiac and cerebrovascular events (TECAB: 12.4% vs MIDCAB: 5.1%, P = 0.358).

CONCLUSIONS

Robotically assisted arrested heart TECAB and robotic MIDCAB perform equally in terms of perioperative results and mid-term follow-up in this single-center patient cohort.

Robotic cardiac surgery in Brazil

BACKGROUND

Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci^® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil.

METHODS

From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy.

RESULTS

The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term.

CONCLUSIONS

Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.

Reviewing hybrid coronary revascularization: challenges, controversies and opportunities

Two main approaches to myocardial revascularization currently exist, coronary artery bypass and percutaneous coronary intervention. In patients with advanced coronary artery disease, coronary artery bypass surgery is associated with improved long term outcomes while percutaneous coronary intervention is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach. This new approach, hybrid coronary revascularization, has shown encouraging early results. Minimally invasive techniques for bypass surgery have played a large part of bringing this approach into contemporary practice.

Liposome Bupivacaine for Postsurgical Analgesia in Patients Undergoing Robotically Assisted Cardiac Surgery

Objective

Despite the advantages of robotically assisted cardiac surgery over conventional open sternotomy, robotically assisted surgery may be associated with substantial postsurgical pain arising from multiple incisions and access ports. This single-site, retrospective chart review evaluated the impact of liposome bupivacaine compared with bupivacaine HCl on postsurgical pain management in patients undergoing robotically assisted endoscopic cardiac surgery.

Methods

Sequential patient cohorts undergoing robotically assisted cardiac surgery received either 0.25% bupivacaine HCl (100 mg in 40 mL, n = 30) or liposome bupivacaine (266 mg in 20 mL, expanded to 40 mL with 0.9% sterile normal saline, n = 30) intraoperatively via equal-volume infiltration across port sites. Outcome measures, collected from the day of surgery through postoperative day 3, were daily and total use of opioid analgesics (converted to morphine equivalents), pain intensity (11-point numeric rating scale), and incidence of postoperative nausea and vomiting.

Results

Median length of hospital stay was 4 days in the liposome bupivacaine group and 3 days in the bupivacaine HCl group. Patients receiving liposome bupivacaine had numerically lower mean pain scores (at six of seven time points), reduced mean opioid consumption, and a reduced incidence of postoperative nausea and vomiting compared with those receiving bupivacaine HCl, although none of the differences reached statistical significance.

Conclusions

Results from this small retrospective, observational study suggest that liposome bupivacaine may improve postsurgical pain relief and reduce postsurgical opioid consumption, in comparison with bupivacaine HCl, in patients undergoing robotically assisted cardiac surgery. Larger prospective studies of liposome bupivacaine in this setting are warranted.

Anatomical features of skull base and oral cavity: a pilot study to determine the accessibility of the sella by transoral robotic-assisted surgery

The role of transoral robotic surgery (TORS) in the skull base emerges and represents the natural progression toward miniinvasive resections in confined spaces. The accessibility of the sella via TORS has been recently described on fresh human cadavers. An anatomic study is mandatory to know if this approach would be feasible in the majority of patients regardless of their oral morphological features. From 30 skull base CT scans from patients who were asked to open their mouth as wide as they can, we measured specific dimensions of the oral cavity and the skull base, such as length of the palate, mouth opening and distance from the sella to the palate. All data were acquired on a sagittal midline plane and on a 25° rotation plane, which simulated the axis of the robotic instruments. Looking at the projection of the dental palatine line on the sella, we studied possible predictive factors of sellar accessibility and tried to bring objective data for surgical feasibility. We also proposed an angle α to study the working angle at the skull base. We observed that the maximal mouth opening was a good predictive factor of sellar accessibility by TORS (p < 0.05). The mouth aperture threshold value for a good sensitivity, over 80 %, was comparable to the mean value of mouth opening in our series, 38.9 and 39.4 mm respectively. Moreover, we showed a statistically significant increase of the working angle α at the skull base comparing the lateral access to the midline one (p < 0.05). This seemed to quantitatively demonstrate that the robotic arms placed at the labial commissure of the mouth can reach the sella. From these anatomical features and previous cadaveric dissections, we assume that TORS may be feasible on a majority of patients to remove pituitary adenomas.

Robotics and surgery: A sustainable relationship?

Robotic surgery is increasingly being employed to overcome the disadvantages associated with use of conventional techniques such as laparoscopy. However, despite significant promise, there are some clear disadvantages and robust evidence base supporting the use of robotic assistance remains lacking. In this paper, the advantages and drivers for robotics will be discussed, its drawbacks and its future role in surgery.

Association of Robotic Totally Endoscopic Coronary Artery Bypass Graft Surgery Associated With a Preliminary Cardiac Enhanced Recovery After Surgery Program: A Retrospective Analysis

OBJECTIVES

The robotic totally endoscopic coronary artery bypass graft (TECAB) surgery reduces patients' recovery time. The present trial investigated the feasibility and safety of an initial enhanced recovery after surgery (ERAS) path for patients undergoing robotic beating-heart TECAB and compared it with both conventional surgery and traditional perioperative care. It was hypothesized that the preliminary ERAS pathway associated with a beating-heart TECAB procedure could have a synergistic effect on postoperative patient care.

DESIGN

Observational retrospective study.

SETTING

University hospital.

PARTICIPANTS

Patients scheduled for coronary artery bypass graft and undergoing robotic beating-heart TECAB (n = 38) were compared with those undergoing standard surgery and perioperative care (n = 33). The outcomes were the possibility of tracheal extubation at the end of the surgery and the incidence of postoperative complications.

MEASUREMENTS AND MAIN RESULTS

The main comorbidities were similar between the 2 groups. Extubation on the operating table in the TECAB group was possible in all cases without requiring prompt endotracheal tube reinsertion. The proportion of patients transfused was significantly lower in the TECAB group (p = 0.009). In addition, the duration of intensive care unit and hospital stay were reduced significantly by 24 hours and by 4 days, respectively, in the TECAB group compared with the standard group (p< 0.05).

CONCLUSIONS

The present results suggested that a program coupling a beating-heart TECAB with a preliminary ERAS path for patients requiring a single coronary revascularization is feasible and safe. This approach could reduce postoperative mechanical ventilation time, transfusion rate, and both intensive care unit and hospital stay.

How to perform a coronary artery anastomosis in complete endoscopic fashion with robotic assistance

Current technology in robotic surgery allows us to perform myocardial revascularization procedures in a totally endoscopic fashion. We will describe the technique of choice for left internal mammary artery to left anterior descendent artery anastomosis with the use of cardiopulmonary bypass machine. The method is efficient and there is long term follow-up showing similar patency of the graft when compared to conventional methods (when performed through sternotomy).

Robotically assisted totally endoscopic coronary artery bypass surgery

Robotically assisted totally endoscopic coronary artery bypass surgery has emerged as a feasible and efficient alternative to conventional full sternotomy coronary artery bypass graft surgery in selected patients. This minimally invasive approach using the daVinci robotic system allows fine intrathoracic maneuvers and excellent view of the coronary arteries. Both on-pump and off-pump operations can be performed to treat single and multivessel disease. Hybrid approaches have the potential of offering complete revascularization with the "best of both worlds" from surgery (internal mammary artery anastomosis in less invasive fashion) and percutaneous coronary intervention (least invasive approach). In this article we review the indications, techniques, short and long term results, as well as current developments in totally endoscopic robotic coronary artery bypass operations.

Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects

Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.

Robotic surgery in cardiology: a safe and effective procedure

Objective:

To evaluate the short and medium-term outcomes of patients undergoing robotic-assisted minimally invasive cardiac surgery.

Methods:

From March 2010 to March 2013, 21 patients underwent robotic-assisted cardiac surgery. The procedures performed were: mitral valve repair, mitral valve replacement, surgical correction of atrial fibrillation, surgical correction of atrial septal defect, intracardiac tumor resection, totally endoscopic coronary artery bypass surgery and pericardiectomy.

Results:

The mean age was 48.39±18.05 years. The mean cardiopulmonary bypass time was 151.7±99.97 minutes, and the mean aortic cross-clamp time was 109.94±81.34 minutes. The mean duration of intubation was 7.52±15.2 hours, and 16 (76.2%) patients were extubated in the operating room immediately after the procedure. The mean length of intensive care unit stay was 1.67±1.46 days. There were no conversions to sternotomy. There was no in-hospital death or deaths during the medium-term follow-up. Patients mean follow up time was 684±346 days, ranging from 28 to 1096 days.

Conclusion:

Robotic-assisted cardiac surgery proved to be feasible, safe and effective and can be applied in the correction of various intra and extracardiac pathologies.

The midterm outcome and MACE of robotically enhanced grafting of left anterior descending artery with left internal mammary artery

BACKGROUND

We assessed the midterm outcome and the incidence of major adverse cardiovascular events in UK's largest Da Vinci assisted robotic coronary revascularisation cohort. This study was set up at the Imperial College NHS Trust, St. Mary's Hospital, London, United Kingdom.

METHOD

Benchmarking approach through retrospective audit of the regional outcomes against standards in the published literature. Data was collected from the patient's records, communication with the primary care physicians and the national strategic tracing service. The results were compared with the published literature. Patients who underwent robotic assisted coronary revascularisation were included. Other robotic procedures or minimally invasive revascularisation without the use of the Da Vinci robot were excluded. The main outcome measure was the midterm survival up to five years and the incidence of major adverse cardiovascular events (MACE) up to three years.

RESULTS

Since April 2002, one hundred consecutive patients underwent either off pump robotic assisted single vessel small thoracotomy (SVST, n=88), or off pump total endoscopic coronary artery bypass grafting (TCAB, n=12). All patients were operated on by the same primary surgeon but different assisting surgeons. All patients received a left internal mammary arterial (LIMA) graft as planned. The primary outcome of total one month and three years MACE and up to five year survival was 0, 9 and 96% respectively.

CONCLUSIONS

The procedural success rates in terms of morbidity and mortality up to five years are compatible to the outcomes observed outside the United Kingdom. These results are not inferior to that of conventional off pump single vessel coronary surgery or percutaneous coronary intervention to the LAD.

Systematic review of robotic-assisted, totally endoscopic coronary artery bypass grafting

BACKGROUND

Advancements in surgical robotic technology over the last two decades have enabled coronary artery bypass grafting to be performed totally endoscopically, and have the potential to significantly change clinical practice in the future.

METHODS

A systematic review of studies reporting clinical outcomes of total endoscopic coronary artery bypass grafting (TECABG) was performed.

RESULTS

14 appraised studies included 880 beating heart TECABGs, 360 arrested heart TECABGs, 633 one-vessel operations and 357 two-vessel operations. Patients were generally low-risk. There was a significant learning curve. The weighted means for short-term beating heart and arrested heart TECABG results respectively were: intraoperative exclusion rate of 5.7% and 1.9%, intraoperative conversion rate of 5.6% and 15.0%, all-cause mortality of 1.2% and 0.4%, stroke of 0.7% and 0.8%, myocardial infarction of 0.8% and 1.8%, new onset atrial fibrillation of 10.7% and 5.1% and post-operative reintervention rate of 2.6% and 2.3%. The overall rate of short term postoperative graft patency for beating heart and arrested heart TECABG was 98.3% and 96.4% respectively.

CONCLUSIONS

Appropriate patient selection was important in minimizing the risk of intraoperative and postoperative complications. Short-term outcomes of both beating and arrested heart TECABG were acceptable, but results so far have been heterogeneous. There were fewer studies reporting intermediate to long-term outcomes, but results were encouraging, and further investigation and development of the procedure is warranted.